Kansas Technical Assistance System Network (TASN)
provides technical assistance to support school districts’ systematic implementation of evidence-based practices.

Emergency Safety Intervention (ESI) Sample Medical Form

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Emergency safety intervention law states that emergency safety intervention must not be used with a student if the student is known to have a medical condition that could put the student in mental or physical danger as a result of the emergency safety intervention. The existence of such medical condition must be indicated in a written statement from the student's licensed health care provider, a copy of which must be provided to the school and placed in the student's file. This written statement must include an explanation of the student's diagnosis, a list of any reasons why an emergency safety intervention would put the student in mental or physical danger, and any suggested alternatives to the use of emergency safety interventions. This is a template that schools may provide to a parent so that the parent may request information from the child's licensed health care provider that the parent needs to fulfill the requirements of K.S.A. 2016 Supp. 72-89d03(b). This template does not include any releases of information that may be necessary, depending on the situation, to share or release information to the school. Any necessary releases should be attached to this template, if used.